Page 26

Louisiana Medicaid Eligibility Manual Application Processing

Issued January 7, 2026 Replaced July 16, 2024 Page 26 of G-0000 Revised/added text indicated by underscore Deleted text indicated by “**”

than 1,875 grams (4 pounds, 2 ounces); - If the gestational age is 35 weeks and the weight at birth is less than 1,700 grams (3 pounds, 12 ounces); - If the gestational age is 34 weeks and the weight at birth is less than 1,500 grams (3 pounds, 5 ounces); - If the gestational age is 33 weeks and the weight at birth is at least 1,200 grams, but no more than 1,325 grams (2 pounds, 15 ounces); or 3. An allegation or diagnosis of Down syndrome.

G-1700 RE-USING THE APPLICATION FORM An application form may be reused to open a new application only in the following situations:  To reopen an application rejected in error; or  To reopen an application that was denied for failure to return documentation, when needed documentation is returned within 30 days; or  To reopen a Spend-Down MNP case when there is no break in quarters of coverage. Applications Rejected in Error Use the previous application date as the date of application when reopening an application rejected in error, or upon reconsideration resulting from an appeal request. Contact the applicant if additional information is needed to determine eligibility. If additional information is required, allow the applicant time to return the information.

Applications That Were Denied Use the previous application date as the date of application when needed documentation is received within 30 days of the mail date of the decision notice.

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Page 26

Official source

Louisiana Medicaid Eligibility Manual Application Processing

Issued January 7, 2026 Replaced July 16, 2024 Page 26 of G-0000 Revised/added text indicated by underscore Deleted text indicated by “**”

than 1,875 grams (4 pounds, 2 ounces); - If the gestational age is 35 weeks and the weight at birth is less than 1,700 grams (3 pounds, 12 ounces); - If the gestational age is 34 weeks and the weight at birth is less than 1,500 grams (3 pounds, 5 ounces); - If the gestational age is 33 weeks and the weight at birth is at least 1,200 grams, but no more than 1,325 grams (2 pounds, 15 ounces); or 3. An allegation or diagnosis of Down syndrome.

G-1700 RE-USING THE APPLICATION FORM An application form may be reused to open a new application only in the following situations:  To reopen an application rejected in error; or  To reopen an application that was denied for failure to return documentation, when needed documentation is returned within 30 days; or  To reopen a Spend-Down MNP case when there is no break in quarters of coverage. Applications Rejected in Error Use the previous application date as the date of application when reopening an application rejected in error, or upon reconsideration resulting from an appeal request. Contact the applicant if additional information is needed to determine eligibility. If additional information is required, allow the applicant time to return the information.

Applications That Were Denied Use the previous application date as the date of application when needed documentation is received within 30 days of the mail date of the decision notice.